Should a critically ill newborn with little chance of long-term survival be kept alive against the parents' wishes? Should you find out if you're at risk for a disease that can't be prevented, treated or cured?
These are the kinds of questions Ruth Macklin, a national authority on bioethics, wrestles with every day. In 1976, Macklin left a tenured teaching position at Case Western Reserve University in Cleveland, where she'd earned a doctorate in philosophy, to pursue bioethics at the Hastings Center in Briarcliff Manor, New York.
"Bioethics enables me to do what I did in philosophy but to apply it to something practical," she says.
In a stuffy room at a college, six weary interns wait for the professor. Macklin asks them to describe an ethical issue from their own experience.
An intern from India tells this story: An elderly man in the late stages of heart disease has come to the emergency room on numerous occasions with severe difficulty breathing. Each time, he's put on a ventilator. After several days he's sent home, where he's bedridden. A couple of weeks later he is back again, and the process is repeated.
The intern's concern is that the short-term treatment is very expensive. One intern tells Macklin, "This guy will only live a few more weeks. How many times can we keep doing this?"
But Macklin doesn't see money as the primary issue. "Might he be enjoying himself, even if he is confined to bed? Perhaps he has grandchildren who come visit him. Do you know anything about his perception of his own life?" The intern admits he doesn't.
This attitude disturbs Macklin very deeply. She believes that over the past decade, more and more young doctors have taken the view that their obligation to society is more important than their obligation to individual patients.
"This lack of advocacy has eroded a very important ethical feature of the doctor-patient relationship. The traditional [philosophy] of medicine teaches the doctor to focus on the needs of the patient, not to ask, 'Hasn't this patient cost society enough money already?' Patients have the right to make the wrong decision."
But bioethics isn't the only field that requires tough ethical choices. Michael Josephson is a former law professor in Los Angeles. He specializes in teaching ethics courses to government officials, businesspeople and average citizens, tackling everything from state wrongdoing to corporate misconduct.
Across the country, business and government leaders are attending Josephson's seminars to re-educate themselves. The sessions are entertaining and combative, but their message is simple: ethical values are more than a series of rules. Josephson encourages people to look beyond the letter of the law to such principles as honor, fairness, honesty and justice.
Josephson began teaching ethics in 1976, when he was assigned a Watergate-inspired course on legal ethics. Later that year, he began to think about the increasing distance between society's emphasis on measures designed to prevent bad conduct and its incentives to promote good behavior.
In Los Angeles, he founded the nonprofit Joseph and Edna Josephson Institute of Ethics, named for his parents, and started offering classes. He's taught thousands of people in hundreds of companies and organizations. One of his main rules is: "We judge ourselves by our best intention, but we are judged by our last worst act."
Josephson says personal values are the starting place for effective political ethics. He's optimistic that every leading business and government organization will someday have an ethics education program. "Without it, they're going to get chewed up from inside and outside."
John Gawthrop is a professional ethicist. "As a society, we need more attention to ethics," he says. "More and more people are struggling with these issues in all aspects of their lives."
Gawtrop learned from personal experience. "Before I took my training, I worked as a counselor in a halfway house for paroled adult ex-offenders. I had to also be their guard, monitoring their comings and goings and writing reports for the national parole service.
"This dual relationship became [difficult]. I had no ethical training, no code of ethics, no professional affiliation to which I could refer for guidance. This became one of my reasons for focusing on ethics when I went back for graduate training later."
Gawthrop encourages interested students to pursue the field. "If someone has a genuine interest and the skills to do this work, I'm all for it. I know it's sorely needed and people are genuinely appreciative of the knowledge, skills and power it gives them to deal with ethical issues successfully. Being an ethicist has shown me that I have something to offer others, something of value that promotes the advancement of integrity."